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Journal of Social Work Practice in the

Addictions
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Couple Therapy Treatments for

Substance Use Disorders: A Systematic
Review
a
Kara Fletcher MSW
a
School of Social Work , McGill University , Montreal , Quebec ,
Canada
Published online: 13 Nov 2013.

To cite this article: Kara Fletcher MSW (2013) Couple Therapy Treatments for Substance Use
Disorders: A Systematic Review, Journal of Social Work Practice in the Addictions, 13:4, 327-352, DOI:
10.1080/1533256X.2013.840213

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 Journal of Social Work Practice in the Addictions, 13:327–352, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: 10.1080/1533256X.2013.840213

ARTICLES

Couple Therapy Treatments for Substance Use

Disorders: A Systematic Review

KARA FLETCHER, MSW

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PhD Candidate, School of Social Work, McGill University, Montreal, Quebec, Canada

Social workers inevitably encounter couples suffering as a result

of one partner’s substance use disorder. Couples might want to
address the impact of the addiction on their couple relationship.
Certain models of couple therapy have been well studied as inter-
vention tools in this particular context. This article synthesizes what
is known about couple therapy in the context of substance use
disorders, through employing a systematic review of existing litera-
ture published in the past 20 years (1992–2012). Limitations and
identified gaps in the existing literature are discussed, and recom-
mendations are offered for future research on treating couples in
the context of substance use disorders.

KEYWORDS addiction, behavioral couples therapy, couple ther-

apy, substance abuse, substance dependence, systematic review

Addiction is a chronic relapsing disorder that can have a deleterious impact

on couple relationships. Partners living with individuals with substance
dependence issues present with as many psychosocial difficulties as the
substance-dependent person (Dethier, Counerotte, & Blairy, 2011). Primarily,
substance dependence can impede couple intimacy and the development of
trust within the relationship, as substance-dependent individuals often lie

Received July 23, 2013; revised August 20, 2013; accepted August 20, 2013.
Editor’s Note: This article makes reference to many studies conducted by the late Dr.
William Fals-Stewart. Readers should be aware that some of his research has been called into
question on ethical grounds.
Address correspondence to Kara Fletcher, McGill University, School of Social Work,
3506 University Street, Room 300, Montreal, QC H3A2A7, Canada. E-mail: kara.fletcher@
mail.mcgill.ca

327
 328 K. Fletcher

about their substance use, and will continue to use these substances despite
their negative impact on the couple relationship (Stanton, 2005). There is also
evidence for the cooccurrence of substance dependence and intimate part-
ner violence (McCollum, Stith, Miller, & Ratcliffe, 2011). Studies have found
that drug and alcohol use are both independent predictors of intimate part-
ner violence (Moore & Stuart, 2004; Stuart, Moore, Kahler, & Ramsey, 2003).
A couple’s experience of distress can be both a precursor to and a risk for
continued substance abuse within a relationship (Kirby, Dugosh, Benishek,
& Harrington, 2005). Even when an individual within a couple has started
recovery from alcohol or drug dependence, couple conflict can precipitate a
relapse (Stanton, 2005).
Within the family system, substance use disorders can become the
focus of many interactions and relations among members (Saatcioglu,
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Erim, & Cakmak, 2006). Numerous studies demonstrate the family needs
to be involved in treatment as much as the substance-abusing individual
(Benishek, Kirby, & Dugosh, 2011; Fischer & Wiersma, 2012; Saatcioglu et al.,
2006). Relatedly, research has found that including the partner in therapy is
predictive of successful treatment (Heinz, Wu, Witkiewitz, Epstein, & Preston,
2009; Nelson & Sullivan, 2007). As early as the 1970s, the National Institute
on Alcohol Abuse and Alcoholism identified couple and family therapy as
a prominent treatment advance in the psychotherapy of alcoholism (Ruff,
McComb, Coker, & Sprenkle, 2010).
Despite the impact of substance use disorders on the family system and
the couple relationship more specifically, treatment often occurs separately
(Stanton, 2005). That said, research is increasingly considering the couple
relationship in substance-dependence treatment and the potential for couple
therapy as a modality within this context (Bischoff, 2008). More and more
in the past 20 years, couple therapy has been studied as a treatment for
substance-dependent persons and their partners. This review assesses the
clinical effectiveness of couple therapy for substance use disorders.

TERMINOLOGY

The definitional boundaries of what addiction is have been changed multiple

times (Reinarman, 2005). Addiction was relabeled dependence in 1964 by the
World Health Organization, as it was thought that the word addiction was
too closely linked to opiate use (Edwards, 2012). Recently, the fifth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American
Psychiatric Association, 2013) was released, and combined the diagnostic
categories for substance abuse and substance dependence. These diagnoses
have been replaced with the term substance use disorders (O’Brien, 2011).
The substance abuse category has been removed as the committee argues
that there is not enough evidence of an intermediate state between substance
 Couple Therapy Treatments for Substance Use Disorders 329

use and substance dependence (O’Brien, 2011; Saunders, 2007). For the
purposes of this article, the DSM–5 definition of substance use disorder,
which is “a cluster of cognitive, behavioral, and physiological symptoms
indicating that the individual continues using the substance despite signif-
icant substance-related problems” (American Psychiatric Association, 2013,
p. 483) is used to refer to substance addiction. Addiction, substance use
disorder, and dependence all refer to a compulsive drug-taking condition
(O’Brien, Volkow, & Li, 2006), and for the purpose of this review, these
terms are used with that intended definition. Substance abuse is only used
in reference to research specific to that phenomenon.

METHOD
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Sample
This comprehensive and systematic literature review assessed the clinical
effectiveness of couple therapy for substance use disorders. A detailed search
strategy examined potentially relevant randomized control studies of couple
therapy in the context of addiction published between 1992 and 2012.

Search Strategy
The search strategy involved two steps. First, the following electronic
resources were searched: ProQuest Central, OVID, PsychInfo, PubMed,
Science Direct, and Medline. Electronic databases were searched individu-
ally. The search terms alcohol, drug, substance, addiction, alcoholic, couple,
marital, conjoint, dyadic, therapy, and intervention were integrated into
database-specific search strings. Combined, the initial database search identi-
fied 1,552 hits, many of which were repetitive across databases. All identified
titles and abstracts were screened, and the quality and eligibility of the stud-
ies was assessed. Titles and abstracts in the initial search unrelated to the
topic of couple therapy or substance use were excluded.
Second, reference lists taken from existing reviews on couple-based
interventions and addiction (n = 6) identified by the first step were reviewed
in an effort to locate references not found through the database-specific
search. In total, 136 relevant articles were found among the database search
and by examining the existing reviews. Eighteen articles and 16 unique
studies met the final inclusion criteria and were included in the review.

Inclusion Criteria
Studies with a focus on couple therapy or couple interventions in the context
of addiction or substance dependence from the past 20 years (dating from
1992) were included. A large time frame was used in an effort to gain an
accurate picture of what is currently understood about couple therapy within
 330 K. Fletcher

this context and how it has been studied. Studies needed to meet the follow-
ing criteria: included one or more treatment groups in which partners of a
substance-addicted adult were involved in couples treatment to (a) improve
the couple relationship (couple adjustment, individual adjustment of the per-
son living with the addiction and individual adjustment for the romantic
partner) or (b) aid in the recovery of the individual living with the addiction
(outcome data on alcohol or drug use by the person with the substance-
dependence issue or drug or alcohol treatment or attendance); compared
couple therapy to one or more comparison conditions; participants were
randomized to groups; assessed at least one outcome that was relevant to
the couple (e.g., couple adjustment); and involved quantitative analysis.
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Exclusion Criteria
Studies were excluded if they were descriptive studies, did not include alco-
hol or drugs, and did not focus on couple therapy. Studies without control
groups were also excluded to focus on more rigorous randomized control
trial (RCT) studies. Studies in which partners were given individual treat-
ment were excluded, unless this occurred within a control group. Studies
that only considered family therapy were excluded. Studies that were not in
English were also excluded (n = 2). Other articles on couple therapy and
addiction (Epstein et al., 2007; Kelly, Epstein, & McCrady, 2004; McCollum,
Nelson, Lewis, & Trepper, 2005; McCrady, Epstein, & Hirsch, 1999; Meyers,
Miller, Smith, & Tonigan, 2002; Nattala, Leung, Nagarajaiah, & Murthy, 2010;
Rotunda, O’Farrell, Murphy, & Babey, 2008) were excluded because they
either did not have a control group, were not randomized, were not inter-
vention studies, or included family members other than romantic partners.
Qualitative studies were excluded because no substantial qualitative studies
(other than exploratory case studies) on couple therapy and addiction were
found using the outlined search strategy.

ANALYSIS

Given the heterogeneity of topics across existing studies, the included studies
were grouped by topic (cost-effectiveness, children, etc.) and outcomes were
reviewed.

RESULTS

Eighteen articles using 16 unique studies were included in the review.

Fourteen studies were conducted in the United States, one in Australia,
and one in the Netherlands. All studies identified were counseling-based
interventions. Five targeted substance-dependent individuals and their
 Couple Therapy Treatments for Substance Use Disorders 331

partners, and 11 targeted alcohol-dependent individuals and their partners.

Studies that met inclusion criteria overwhelmingly came from research
groups led by O’Farrell and his colleagues, and McCrady and her colleagues.
Both groups use variations of behavioral couples therapy (BCT) and their
research typically employs three different treatment conditions. The 18 stud-
ies were divided into categories based on what variables they studied.
Table 1 provides a summary of all reviewed studies.

Behavioral Couples Therapy

O’Farrell, Fals-Stewart, and colleagues have conducted over three decades of
research on BCT in the context of drug and alcohol addiction. In this review,
BCT studies outnumbered any other theoretical model and comprised the
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majority of studies. BCT theorists posit that family members’ interactions

with the person abusing substances can reinforce their substance-using
behavior (Fals-Stewart, Lam, & Kelley, 2009). BCT developed out of the
Harvard Counseling for Alcoholics Marriages Project (Project CALM). CALM
was developed in the 1980s as one of the first manualized behavioral treat-
ment models for couples treatment and alcohol (Ruff et al., 2010). Within
Project CALM, the couple completes a daily “trust discussion,” also known
as a “sobriety contract” or “recovery contract,” where the individual with
the substance abuse issue contracts to stay abstinent that day (O’Farrell
& Fals-Stewart, 2008). The CALM BCT protocol was created initially to be
used in conjunction with individual treatment; however O’Farrell and Schein
(2011) have since argued that BCT can be used as a stand-alone model.
Only one study examined in this review (Vedel, Emmelkamp, & Schippers,
2008) adapted BCT as a stand-alone model, whereas the rest used BCT in
conjunction with individual behavioral therapy.
BCT has two overarching components: assessing and improving
behavioral interactions between the substance-dependent person and his
or her partner, and improving communication skills within the couple
(Copello, Templeton, & Velleman, 2006). This approach posits if couples
are happier and improve their communication, there will be a lower chance
of relapse (O’Farrell & Clements, 2012). From this perspective, relationship
functioning and substance dependence are reciprocal (Powers, Vedel, &
Emmelkamp, 2008). The model typically involves 12 to 20 weekly couple
sessions in conjunction with individual treatment (Ruff et al., 2010). Most
studies examined within this review have an individually based 4-week
orientation phase, 12 weeks of BCT and individual therapy, and an 8-week
individual discharge phase. Throughout the 12 weeks, the focus of BCT
shifts from recovery and abstinence to the couple relationship (O’Farrell &
Fals-Stewart, 2008). The couple is encouraged to avoid discussion of past
substance abuse and fears about future substance use outside of therapy
sessions (O’Farrell & Schein, 2011).
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TABLE 1 Summary of Included Articles for Review

Intervention (No. of Follow-Up
Reference Sessions) Design Sample (n) Results (Months)
Fals-Stewart, 32, 60-min sessions over a RCT Gay (n = 52) and lesbian For both gay and lesbian participants, BCT 3-, 6-, 9-,
O’Farrell, et al. 20-week period of (n = 48) with alcohol use had a significantly lower percentage of 12-month
(2009) (a) CALM BCT plus IBT or disorder and non- heavy drinking days during year after follow-up
(b) IBT only substance-dependent treatment than IBT-only group
partners Gay couple BCT–IBT contrast: z = −2.11,
p < .05
Lesbian couple BCT–IBT contrast: z = 2.45,
p < .05
All couples who received BCT reported higher
levels of relationship adjustment than IBT
Gay couple BCT–IBT contrast: z = 2.01,
p < .05
Lesbian couple BCT–IBT contrast: z = 1.43,
p < .05

332
Fals-Stewart, 12 sessions of (a) CALM BCT RCT n = 138 married or No difference between groups on drinking 3-, 6-, 9-,
Birchler, et al. plus IBT, or (b) IBT, or (c) cohabiting female behavior; however, BCT group had 12-month
(2006) PACT alcoholic clients and significant improvement in couple follow-up
32 sessions in total non-substance-dependent adjustment compared to PACT (z = 2.02) or
partners IBT (z = 2.15, p < .05)
Fewer days of drinking and higher dyadic
adjustment at 12-month follow-up
DAS BCT: z = 2.44, p < .05, and % days
abstinent BCT: z = –3.32, p < .001
Fals-Stewart et al. (a) BRT, or (b) shortened RCT n = 100 alcoholic male BRT and S–BCT participants had equivalent 3-, 6-, 9-,
(2005) BCT (S–BCT), or (c) IBT, participants and posttreatment and 12-month follow-up in 12-month
or (d) PACT non-substance-abusing reducing heavy drinking outcomes (not follow-up
female partners significant). They were both superior to
other conditions in drinking and dyadic
outcomes, z = 0.95, p < .05. BRT more
cost-effective than S–BCT (z = 2.74, p <
.01), IBT (z = 2.04, p < .05), and PACT (z
= 2.04, p < .05) conditions
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Fals-Stewart et al. Twice weekly for 12 weeks, RCT n = 36 heterosexual married Male partners in BCT condition had fewer At roughly
(2001) (a) IBMM services or or cohabiting couples with positive urine samples during treatment 4 months
(b) BCT plus 1 hr of substance-dependent men than condition: p < .5. BCT group reported
individual IBMM entering methadone higher levels of relationship happiness
maintenance during treatment, F(11, 352) = 1.71, p < .5,
and higher dyadic adjustment at
posttreatment than condition, F(1, 33) =
8.01, p < .01
Fals-Stewart et al. 4-week orientation phase, RCT (not a N = 80 male married or More males in BCT condition reported 3-, 6-, 9-,
(2000) then 12 weekly sessions of unique cohabiting substance- significant reductions in substance use 12-month
(a) IBT or (b) BCT plus study) dependent clients, most (33.83%) than those in IBT condition follow-up
IBT followed by 8-week referred through criminal (24.6%)
discharge phase justice system (n = 68, Effect = 4.92, p = .03
85%) More couples in BCT condition had improved
dyadic adjustment (24.6%) than IBT
condition (14.35%)
Effect = 5.01, p = .03

333
Fals-Stewart et al. Cost outcomes examined in RCT (not a n = 80 married or BCT more cost-beneficial than IBT (average 3-, 6-, 9-,
(1997) 12-weeks of (a) BCT plus unique substance-dependent reduction in social costs from baseline to 12-month
IBT or (b) IBT; in total, study) clients follow-up and for each $100 spent on follow-up
both groups received treatment)
56 treatment sessions Cost: BCT, t = 3.99, p < .001;
IBT, t = 0.85
Fals-Stewart et al. 4-week orientation phase, RCT n = 80 male married or Couples in BCT condition had better 3-, 6-, 9-,
(1996) then 12 weekly sessions of cohabiting substance- relationship outcomes 12-month
(a) IBT or (b) BCT plus dependent clients, most Effect = 13.62, p < .001. Men in BCT follow-up
IBT, followed by 8-week referred through criminal condition reported fewer days of drug use,
discharge phase justice system (n = 68, longer periods of abstinence, and so on
85%) Effect = .96
Difference between groups dissipated by the
12-month follow-up
(Continued)
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TABLE 1 (Continued)
Intervention (No. of
Reference Sessions)
Halford et al. 12 sessions of (a) supportive
(2001) counseling, (b) stress
management, or (c) CALM
BCT alcohol-focused
couples therapy
Kelley & 32 sessions of (a) BCT,
Fals-Stewart (b) IBT, or (c) PACT
(2002)
334
Lam et al. (2009) 12 weekly sessions of (a)
parent training with BCT,
(b) BCT, or (c) IBT; all
conditions in combination
with 12 weekly CBT
sessions
McCollum et al. 12 weekly sessions of (a)
(2003) SCT plus regular agency
treatment, (b) SIT plus
regular agency treatment,
(c) TAU plus “booster”
sessions at follow-up dates
Follow-Up
Design Sample (n) Results (Months)
RCT n = 61 married women Few differences between treatment conditions 6-month
whose husbands are (r < .3) follow-up
alcoholic No clinically significant reduction in drinking
RCT n = 71 children of alcoholic Fathers who participated in BCT had higher 6- and 12-month
men ratings of children’s psychosocial follow-up
n = 64 children of functioning than fathers in IBT or PACT
drug-dependent men Alcohol couples: pre–post effect = .29, post to
6 months = .44, 6–12 months = .46,
p < .01
Drug couples: pre–post effect = .35, post to
6 months = .42, 6–12 months = .39,
p < .01
RCT n = 30 fathers, their female Only parent training with BCT had significant 6- and 12-month
partners, and a custodial effects on all child measures throughout follow-up
child 8–12 years old 12-month follow-up, r = .33 (medium
effect), p < .05
RCT n = 122 women and their Groups did not differ at 1 year posttreatment 3-, 6-, 12-month
partners on alcohol use scale; however, SCT and SIT follow-up
did better at follow-up in drug use scale
than TAU
Alcohol use during treatment: F = 3.256, p =
.004 (ns at 1 year)
Drug use during treatment: F = 2.548, p = .21
(at 1 year SIT and SCT groups, p < .04)
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McCrady et al. 20 weekly sessions of
(2009) (a) ABCT or (b) ABIT
O’Farrell, Weekly BCT for 5–6 months
Choquette, followed by (a) 15
Cutter, Brown, additional conjoint relapse
et al. (1996) prevention sessions over
12 months or (b) no
further treatment
O’Farrell, 10 weeks of (a) IBT, (b) BCT
Choquette, plus IBT, (c) interactional
Cutter, Floyd, couples group (ICT) plus
335
et al. (1996) IBT
O’Farrell et al. Follow-up results to a
(1992) 1985 study; 10 weekly
sessions of (a) IBT, (b)
BCT plus IBT, (c) ICT
RCT n = 102 heterosexual Increase in percentage of days abstinent from 3-, 6-, 9-, 12-,
women and their partners alcohol and decrease in percentage of 15-, 18-month
heavy drinking days follow-up
ABCT still favored during 12-month follow-up
(ß = −.309, p < .05)
RCT n = 59 couples with newly Both BCT and BCT with relapse prevention 12 months after
abstinent alcoholic showed decrease in health care and legal BCT follow-up
husbands costs 12 months after treatment
BCT only, t(28) = 4.72, p < .001
BCT plus relapse prevention, t(29) = 4.93,
p < .001
Benefits exceeded cost of delivering treatment
by more than 5×
Relapse prevention did not lead to greater
cost savings
RCT n = 36 newly abstinent Decreases in health care and legal costs in the 24-month
married male alcoholics 2 years post treatment as compared with follow-up
pretreatment
ICT increased posttreatment costs, IBT had a
significantly more positive benefit-to-cost
ratio than BCT (p = .053)
Service costs lower than baseline costs for
BCT group, t(9) = 2.27, p = .049, and IBT,
t(11) = 5.56, p < .001
BCT reduced system costs significantly more
than ICT, t(20) = 2.12, p = .047
RCT n = 34 couples, where BCT couples had better marital outcomes than 24-month
husbands were alcoholics IBT, t(32) = 2.27, p = .031 follow-up
Only BCT diminished over time after
treatment
Advantages of BCT for drinking outcomes no
longer apparent 2 years after treatment, not
significant
(Continued)
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TABLE 1 (Continued)
Intervention (No. of
Reference Sessions)
Vedel et al. (2008) 10 sessions of (a) stand-
alone BCT (90 min) or (b)
individual CBT (60 min)
Walitzer & 10 weekly 2-hr group
Dermen (2004) sessions of (a) IBT, (b)
AFSI, or (c) AFSI plus BCT
Design Sample (n)
RCT n = 64 alcoholic participants
(n = 30) and their
partners (n = 34)
RCT n = 64 male “problem
drinkers” and their
cohabiting partners
Follow-Up
Results (Months)
BCT and CBT both effective in changing 6-month
drinking behavior after treatment. Effect: follow-up
d = 0.35, p = .238. Posttreatment, BCT
more effectively increased couple
satisfaction than CBT: patient, d = 0.24,
p = .416; partner, d = 0.62, p < .05.
However, this did not hold up at follow-up:
patient, d = 0.06, p = .854; partner, d =
0.17, p = .577
BCT group had fewer heavy drinking days 12-month
(effect = 5.76, p < .05) and more abstinent follow-up
and light drinking days in the year

336
Winters et al. 4-week orientation phase
(2002) plus 12 weeks of (a) BCT
plus IBT and group
therapy or (b) IBT plus
group therapy followed by
an 8-week discharge
phase (56 sessions in total)
RCT n = 75 married or cohabiting
drug-dependent females
following treatment
(12 months), Fs = 4.05, ps = .046
AFSI plus BCT did not have better outcomes
Changes only seen through first 6 months of 3-, 6-, 9-, and
follow-up 12-month
Martial happiness, F = 3.19, p < .05 follow-up
Drug use, F = 1.14, ns, they were not
significant by the end of Year 1

Note. CALM = Counselling for Alcoholics Marriages Project; BCT = Behavioral Couples Therapy; IBT = individually based treatment; RCT = randomized control trial;
PACT = psychoeducational attention-control treatment; DAS = Dyadic Adjustment Scale; BRT = brief model of BCT; S–BCT = shortened BCT; IBMM = individual-
based methadone maintenance; CBT = cognitive behavioral therapy; SCT = systemic couples therapy; SIT = systemic individual therapy; TAU = treatment as usual;
ABCT = alcohol behavioral couples therapy; ABIT = alcohol behavioral individual therapy; ICT = interaction couples therapy; AFSI = alcohol-focused spouse
involvement.
 Couple Therapy Treatments for Substance Use Disorders 337

Alcohol Behavioral Couple Therapy Program

A variation of BCT, the alcohol behavioral couple therapy (ABCT) program
was developed by Epstein, McCrady, and their research team at Rutgers
University. Integrating social learning theory with systems models, this model
assumes that problematic drinking occurs within an interactional context
(McCrady, 2012). The structured program uses “alcohol-focused spouse
involvement” where the nonaddicted spouse is taught skills to deal with
alcohol-related situations (Epstein & McCrady, 1998). The spouse becomes a
secondary therapist or coach for the addicted partner, helping them through
the process of behavioral change (Walitzer & Dermen, 2004). Like the
BCT model, ABCT uses cognitive-behavioral elements to help clients stop
drinking and maintain abstinence (McCrady et al., 1999). ABCT also uses
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behavioral contracts between intimate partners to support abstinence and in

some cases, the use of medication (e.g., Antabuse; Velleman, 2006). ABCT
has since been expanded to include treatment for couples in which one
partner has a drug addiction.

Brief Couple Therapy and Systemic Couple Therapy

Only one study that used a therapeutic model other than BCT met criteria
for this review. This was McCollum, Lewis, Nelson, Trepper, and Wetchler’s
(2003) study that examined the effectiveness of systemic couples therapy
(SCT) in the context of female drug-dependent clients and their partners.
SCT is an integrated model that uses structural, strategic, behavioral, and
Bowenian concepts of family therapy. It was developed to treat females who
have a substance use disorder and their partners, and focuses on patterns and
themes from the substance-dependent individual’s family of origin (Nelson,
McCollum, Wetchler, Trepper, & Lewis, 1996). The goal of this therapy is to
help the woman improve her primary relationship and in turn, foster her
ability to meet treatment goals. There are multiple phases within 12-week
SCT (assessment, goal setting, consolidation, etc.), but it is less structured
than BCT (Nelson et al., 1996).
Participants in McCollum et al.’s (2003) study were randomized into
three treatment conditions: SCT, systemic individual therapy (SIT), and stan-
dard treatment as usual (TAU). Although therapy only occurs with the
individual in SIT, like SCT, the focus of the therapy is altering nega-
tive couple patterns. Using the Addiction Severity Index (ASI; McLellan,
Luborsky, Woody, & O’Brien, 1980) to measure women’s drug use pre- and
posttreatment, results found that women in SIT and SCT did better than the
TAU group at 6 months and 1 year posttreatment (McCollum et al., 2003).
The results of this study suggested the potential benefit of a systemic focus
with this particular population; however, replication is needed to examine
the benefit of this model over other couple therapy models.
 338 K. Fletcher

Behavioral Couples Therapy

BCT AS A TREATMENT FOR ALCOHOLISM

Studies on BCT and alcohol dependence outnumbered other studies in this

review. Only one BCT study (Vedel et al., 2008) did not separate substance-
dependent participants by gender. It was also the only reviewed study
that examined the effectiveness of a brief stand-alone BCT. Vedel et al.
(2008) adapted the CALM protocol, described earlier, to use as a stand-alone
model. Their study compared BCT to individual cognitive behavioral therapy
(CBT). The outcome measures used in the study were couple functioning
and alcohol consumption. BCT was equally effective in decreasing drink-
ing as CBT, and although posttreatment effect size favored BCT, follow-up
showed only a small effect between conditions. BCT was more effective
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than CBT in decreasing couple satisfaction, but the effect size was medium
and there was not a significant change in marital satisfaction scores. The
authors questioned whether decreasing couple dissatisfaction to a nondis-
tressed level was too ambitious for a short-term treatment (10 sessions). BCT
as a stand-alone model requires further research to better understand its
effectiveness.

BCT AND MALE ALCOHOLIC PARTICIPANTS

Results were varied for BCT studies conducted on male alcoholic participants
and their partners. The studies reviewed were Fals-Stewart, Klostermann,
Yates, and Birchler (2005), Halford, Price, Kelly, Bouma, and Young (2001),
O’Farrell, Cutter, Choquette, Floyd, and Bayog (1992), and Walitzer and
Dermen (2004). Primarily, these studies suggest that BCT ameliorates symp-
toms for a specific subset of male alcoholics. For example, Fals-Stewart et al.’s
(2005) study showed positive results for a brief model of BCT (BRT) for male
alcoholic clients. BRT is a form of BCT that has been modified to last for only
six sessions. In this study, BRT showed promise, with higher levels of rela-
tionship satisfaction and positive drinking outcomes during the follow-up
period than individual therapy or psychoeducational control groups. In con-
trast, BCT participants in Walitzer and Dermen’s (2004) study identified as
“problem drinkers” improved in their drinking, but not in their couple satis-
faction. The authors posited this might be a result of their baseline of couple
satisfaction being less distressed in comparison with other samples (Walitzer
& Dermen, 2004). A limitation of using this particular study is that we do not
have a good definitional understanding of “problem drinkers.” As a result
problem drinkers might have a different treatment trajectory than alcoholics,
which could invalidate a comparison.
These studies highlight that BCT interventions could vary substantially
in practice. Although one can assume that treatment application is very
similar within a research group (e.g., O’Farrell’s or McCrady’s studies),
 Couple Therapy Treatments for Substance Use Disorders 339

Walitzer and Dermen’s (2004) use of BCT was specific, focusing on the
relationship-enhancement components of the therapy. They compared
three groups: individual treatment, couples alcohol-focused treatment, and
couples alcohol-focused treatment with BCT. Using their application of BCT,
they found that it did not enhance marital satisfaction compared with the
other groups. This absence of effect in marital satisfaction is in contrast to
other BCT studies (e.g., Fals-Stewart, Birchler, & Kelley, 2006). Clients who
participated with their partners (couples treatment with or without BCT)
did, however, show reduction in drinking.
Halford et al. (2001) completed a couple therapy study with treatment-
resistant clients. They recruited women whose husbands were alcoholics,
but not currently in treatment. They compared the CALM BCT model (using
alcohol-focused couple therapy) with a supportive counseling group and a
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stress management group (both for the female partners). All three treatments
improved emotional distress levels for the wives in the study; however,
none of the treatments improved the husband’s drinking or the couple
relationship. Only 6 of the 21 husbands assigned to the CALM BCT con-
dition completed treatment. The husbands’ resistance to treatment in this
study might account for these results. BCT participants have better treatment
results when they are voluntary (e.g., Fals-Stewart et al., 2005; O’Farrell et al.,
1992).
O’Farrell et al.’s (1992) study suggested that BCT can be effective in
improving couple functioning and drinking outcomes, but found that results
might not be sustainable over time. This article was included in the review
although it presents posttreatment results from an earlier study completed
in 1985. Married male alcoholics were randomly assigned to a condition of
a “no couple-treatment” control group, to 10 weekly sessions of BCT, or
to an interactional couples therapy (ICT) treatment. ICT groups emphasize
catharsis, sharing feelings, problem solving through discussion, and ventila-
tion, and they are not behaviorally focused (O’Farrell et al., 1992). Couple
adjustment and drinking outcomes were measured. Improved outcomes in
couple adjustment and drinking found at 6 months posttreatment in BCT
were not sustained at the 24-month follow-up: There was no longer a sig-
nificant difference in drinking or couple adjustment outcomes between the
ICT group and the BCT group. Drinking adjustment outcomes were not
significant across the three groups. However, BCT and ICT maintained signifi-
cance in couple adjustment over the individual “no couple-treatment” control
group.

BCT AND MALE SUBSTANCE - DEPENDENT PARTICIPANTS

Three articles and two unique studies were reviewed that examined male
drug dependence and couple therapy: Fals-Stewart et al. (2000), Fals-Stewart,
Birchler, and O’Farrell (1996), and Fals-Stewart, O’Farrell, and Birchler, 2001.
 340 K. Fletcher

Fals-Stewart, Birchler, and O’Farrell’s (1996) study was the first random-
ized clinical control trial to examine drug dependence and couple therapy.
Married or cohabiting substance-dependent clients entering outpatient treat-
ment were randomly assigned to a no couples-treatment control group or
12 weekly sessions of BCT. Of the participants, 68.8% were referred by the
criminal justice system. This study had a lower dropout rate than many other
studies, which might have resulted from legal coercion. Couples in the BCT
condition had better relationship outcomes (measured as dyadic adjustment)
than couples in the no-couple treatment control group. Males in the BCT con-
dition reported fewer days of drug use, fewer drug-related arrests, and fewer
drug-related hospitalizations throughout the 12-month follow-up period than
men in the control group.
Fals-Stewart et al.’s (2000) article reanalyzed data from Fals-Stewart,
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Birchler, and O’Farrell’s (1996) study. Outcomes of the individually based

treatment (IBT) and BCT group were compared in terms of individual change
rates on primary outcome measures (significant reductions in substance use,
improvement in dyadic adjustment, significant worsening in either of these
domains, or no significant change from pretreatment functioning). These
findings enhanced Fals-Stewart, Birchler, and O’Farrell’s (1996) results that
BCT was more effective in reducing substance use and increasing dyadic
adjustment than IBT alone. Due to small sample size, the authors could not
examine participant, therapist, or treatment factors that could discriminate
who improved, deteriorated, or showed no change.
Fals-Stewart et al. (2001) completed the first RCT to look at BCT in the
context of substance-abusing men entering methadone maintenance (MM)
treatment. Married or cohabiting men entering MM treatment were randomly
assigned to either an individual-based methadone maintenance (IBMM) pro-
gram, or an intensive BCT treatment condition. IBMM is individually based
treatment in addition to MM. Drug use and relationship satisfaction mea-
sures were collected at baseline, during treatment (weekly), and at 4 months
posttreatment follow-up. Males in the BCT condition had significantly fewer
positive drug tests than those in the IBMM condition, suggesting a reduction
in drug use during treatment. Compared to the IBMM condition, couples
in the BCT group reported significantly higher levels of relationship satis-
faction during treatment and higher relationship adjustment posttreatment.
Finally, participants in the BCT condition reported greater reductions in drug
use, family problems, and social problems from baseline to posttreatment
than did IBMM participants. These findings might not be generalizable to
other couple groups (e.g., heterosexual drug-dependent females on MM),
and the follow-up period was relatively short, making it difficult to ascer-
tain the sustainability of these interventions. Although there were only two
unique studies to consider, BCT appears to offer a promising intervention
for couples in this context. Factors such as small sample size and dissipation
of treatment effects over time encourage replication of these studies.
 Couple Therapy Treatments for Substance Use Disorders 341

BCT AND GAY AND LESBIAN ALCOHOLIC PARTICIPANTS

Relationship quality is equally impacted by alcohol use disorders (AUDs)

for gay and lesbian couples as it is for heterosexual couples (Fals-Stewart,
O’Farrell, & Lam, 2009). Only one study provided a perspective on the utility
of couple therapy in treating same-sex couples. Fals-Stewart, O’Farrell, and
Lam (2009) conducted two separate trials, one with gay participants and one
with lesbian participants, to examine the efficacy of BCT with gay and lesbian
clients with AUDs and their non-substance-dependent partners. Outcomes
were compared between BCT and IBT throughout treatment and over a 12-
month posttreatment follow-up period. For both gay and lesbian couples,
those who received BCT reported significantly lower proportions of days of
heavy drinking in the year after treatment than did those couples in the IBT
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group. The BCT group also reported higher levels of relationship adjustment
than the IBT group at the end of treatment and in the year after treatment.
This study had a small sample size, and one study on the effect of BCT
in treating gay and lesbian couples is insufficient to draw any substantive
conclusions, but these initial results recommend future studies.

BCT AND FEMALE ALCOHOLIC PARTICIPANTS

Despite evidence that women respond differently to alcohol and drug treat-
ment, many approaches are designed to treat men (Winters, Fals-Stewart,
O’Farrell, Birchler, & Kelley, 2002). Female alcoholics are seen to have
more personal problems than male alcoholics (Saatcioglu et al., 2006).
Two unique studies examined female alcoholic participants and BCT: Fals-
Stewart, Birchler, and Kelley (2006) and McCrady, Epstein, Cook, Jensen, &
Hildebrandt (2009). These results are in contrast to some studies with male
participants (Fals-Stewart et al., 1996; O’Farrell et al., 1992).
Fals-Stewart, Birchler, and Kelley (2006) randomized married or cohab-
iting female alcoholic clients and their non-substance-abusing male partners
to either a CALM BCT program, IBT only, or a psychoeducational attention-
control treatment (PACT). During treatment there were no significant
differences across groups in drinking frequency; however, couple adjust-
ment significantly improved in the CALM BCT group. At 1-year follow-up,
compared with IBT or PACT, the BCT group had fewer days of drinking,
higher dyadic adjustment, and a reduction in partner violence.
McCrady et al. (2009) randomized heterosexual women participating in
an alcohol behavioral couples therapy (ABCT) program compared to alcohol
individual behavioral therapy (ABIT). Compared with the ABIT group, during
the 6 months of treatment, women in the ABCT group increased their per-
centage of days abstinent and decreased their percentage of heavy drinking
days significantly. At the 12-month follow-up, ABCT continued to be more
effective than the ABIT condition. Of note, more than one quarter of the
female sample had male partners who met criteria for a current or past AUD.
 342 K. Fletcher

BCT AND FEMALE SUBSTANCE - DEPENDENT PARTICIPANTS

Only one study that met inclusion criteria examined BCT and female
substance-dependent participants. Winters et al. (2002) conducted the first
RCT to examine the efficacy of BCT in treating drug-dependent female
clients. Participants were randomly assigned to a BCT condition, which con-
sisted of group, individual, and behavioral couple therapy sessions, or an
equally intensive IBT condition, which involved both group and individual
counseling. During treatment, the BCT group had significantly higher levels
of relationship satisfaction than IBT, and both conditions were equally effec-
tive in reducing substance abuse. During the 3-month and 6-month follow-up
posttreatment, participants in the BCT condition reported fewer days of sub-
stance use; longer periods of abstinence; lower levels of alcohol, drug, and
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family problems; and higher relationship satisfaction compared with the IBT
condition. Congruent with other BCT studies (e.g., Fals-Stewart et al., 1996),
at 9-month and 1-year follow-up, differences in relationship satisfaction and
number of days abstinent declined. This study had good results, but they
were not sustained over time.

BCT AND CHILDREN

Parental functioning impacts their child’s functioning (Saatcioglu et al., 2006).

Children with substance-dependent parents have a high potential for expo-
sure to emotional or psychological problems (Saatcioglu et al.). Two studies
met criteria that examined child functioning and BCT: Kelley and Fals-Stewart
(2002), and Lam, Fals-Stewart, and Kelley (2009). Kelley and Fals-Stewart’s
(2002) study was the first to examine the effect of BCT on children with
alcohol- or drug-dependent fathers. They separated couples into a drug treat-
ment group (n = 64), and an alcohol treatment group (n = 71). Participants
in both groups were randomized into three treatment conditions: BCT, IBT,
and PACT. Results from both treatment groups had the same patterns. BCT
improved children’s functioning after treatment, and during the follow-up at
6 months and 12 months posttreatment, more than IBT and PACT conditions.
The BCT condition had higher dyadic adjustment for both groups than the
other conditions.
Lam et al. (2009) conducted a pilot study to evaluate the effect of parent
skills training with BCT on children’s behavioral functioning. They investi-
gated whether adding skills training to BCT with alcoholic fathers would
have more benefits for the couple’s children. The pilot study randomized
30 alcoholic fathers to a parent training with BCT group, or BCT without
parent training or IBT. Children did not attend therapy sessions; however,
they completed self-reports of internalizing symptoms at each assessment.
Parents completed measures about their own parenting and their child’s
behaviors at pre- and posttreatment and at 6- and 12-month follow-ups. Only
parent training participants (with BCT) reported significant improvements
 Couple Therapy Treatments for Substance Use Disorders 343

on parenting practices and all child symptom measures throughout the 12-
month follow-up. These results were positive and could benefit from being
replicated with a larger sample size. Two studies are insufficient to draw
conclusions about the impact of BCT on children living with alcohol- or
drug-dependent parents, but these initial studies offer promising family-wide
results for involving partners in substance treatment.

BCT AND COST - EFFECTIVENESS

When providing couple therapy in the context of addiction, questions arise

as to whether couple therapy is more cost-effective than individual therapy.
As a result, RCT studies examining the cost-effectiveness of couple therapy
in the context of addiction were reviewed to understand the economic com-
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parison of providing couple therapy as opposed to another treatment model

(individual or group). Four studies on cost-effectiveness met criteria for this
review: Fals-Stewart et al. (2005), Fals-Stewart, O’Farrell, and Birchler (1997),
O’Farrell, Choquette, Cutter, Brown, et al. (1996), and O’Farrell, Choquette,
Cutter, Floyd, et al. (1996). Both O’Farrell, Choquette, Cutter, Brown, et al.
(1996) and O’Farrell, Choquette, Cutter, Floyd, et al. (1996) examined
cost-effectiveness by looking at newly abstinent male alcoholics.
O’Farrell, Choquette, Cutter, Brown, et al. (1996) studied couples who
had participated in and completed weekly BCT for 5 to 6 months. Couples
were randomly assigned to receive or not receive an additional 15 sessions
of couples relapse prevention throughout the next 12 months. Measurements
for cost–benefit analysis included baseline and follow-up costs incurred
from alcohol-related health care and legal system use, the cost of deliver-
ing both BCT and relapse prevention, monetary benefits of reduced health
and legal costs, and benefit-to-cost comparisons. The cost of treatment deliv-
ery, and health and legal service use, were measured for the 12 months
before and after BCT. Adding relapse prevention to BCT resulted in less
drinking and improved couple adjustment; however, it did not have greater
cost-effectiveness in health and legal service use. Treatments were equally
cost-effective in couple adjustment, and BCT was more cost-effective in terms
of abstinence.
O’Farrell, Choquette, Cutter, Floyd, et al. (1996) assigned newly absti-
nent male alcoholics to a no BCT group, an interactional couples group
(ICT), or to 10 weekly sessions of BCT. Measurements for cost–benefit analy-
sis included the cost of delivering both BCT and relapse prevention, baseline
and follow-up alcohol-related costs (health and legal), and benefit-to-cost
comparisons. Like O’Farrell, Choquette, Cutter, Brown, et al. (1996), BCT
was more cost-effective in reducing alcohol-related costs. Both individual
treatment and BCT had equivalent couple adjustment outcomes.
Using data from Fals-Stewart et al.’s (1996) clinical outcome study,
Fals-Stewart et al. (1997) examined cost outcomes for cohabiting
substance-dependent male participants in a BCT or an IBT-only group.
 344 K. Fletcher

Estimating the social costs the year before and the year after treatment, they
found BCT was more cost-effective than IBT with particular reductions in
inpatient hospitalization, long-term residential care, and incarceration. Total
savings for clients in collective social costs from baseline to follow-up were
about $5,000 per client higher than the IBT control group. Clients in the
IBT group relapsed more than clients in the BCT group, and relapses can
incur large costs. This study was done with participants involved in the crim-
inal justice system, so cost-effectiveness might look different with another
population of participants.
Fals-Stewart et al. (2005) also measured the cost-effectiveness of BCT
and BRT. This study found that BRT was more cost-effective than other con-
ditions (BCT, PACT, and IBT); however, the authors were cautionary with
their results as their study did not complete a follow-up measure of cost-
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effectiveness (e.g., at 1 year following treatment). Although brief BCT might

appear to be more cost-effective, various factors could warrant or encourage
the use of standard BCT, such as couples with high levels of distress, or indi-
viduals who continue to struggle with maintaining abstinence. Across studies,
outcomes demonstrated that providing BCT in the context of substance
dependence is cost-effective, particularly in terms of fewer relapses.

DISCUSSION

BCT is arguably the relational approach to treating substance dependence

most based on evidence (O’Farrell & Clements, 2012; Ruff et al., 2010;
Shadish & Baldwin, 2005; Stanton & Shadish, 1997). This theoretical model
has positive results with both heterosexual couples and same-sex couples.
The action of BCT appears to be the ability to enhance satisfaction within
the couple relationship, which, in turn, leads to a reduction in substance use
(Fals-Stewart, Klostermann, & Yates, 2006; Powers et al., 2008). BCT is also
proven to be cost-effective (e.g., Fals-Stewart et al., 2005).
Treatment effects of BCT are promising; however, there is evidence that
they also dissipate over time. In their meta-analysis of BCT studies, Powers
et al. (2008) also noted that the pattern of results varied as a function of
time. However, another meta-analysis of 30 randomized control BCT stud-
ies indicated that an average couple receiving BCT has better outcomes
than those couples who receive no treatment (Shadish & Baldwin, 2005).
Although this review found a variety of results for BCT, couples who are
treated together were seen to do better (at least when measured at short-term
follow-up) than couples treated separately. There is a potential for future
studies to examine whether couple treatment improves couple functioning
regardless of modality, or whether different treatment modalities produce dif-
ferent results. With the exception of three studies—Fals-Stewart et al. (2005),
O’Farrell et al. (1992), and Walitzer and Dermen (2004)—studies did not
 Couple Therapy Treatments for Substance Use Disorders 345

compare models of couple therapy (e.g., BCT and emotional-focused cou-

ples therapy). Assessing whether there are differences in outcome between
BCT and other couple therapy models is an important next step.
Regardless of modality (BCT, IBT, etc.), most clients entering addiction
treatment are not experiencing sustained treatment effects (Office of Applied
Studies, 2000). For example, of clients admitted to the U.S. public treatment
system in 1999, 60% were reentering treatment; 23% for the second time, 13%
for the third time, 7% for the fourth time, 4% for the fifth time, and 13% for
the sixth time or more (Office of Applied Studies). Researchers have found
that an individual’s relational and social stability is more predictive of the
longer term sustainability of treatment gains than the severity or chronicity
of their addictive disease (e.g., Vaillant, 1988). More studies that focus on
strengthening an individual or a couple’s relational functioning in the context
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of addiction are needed.

LIMITATIONS OF EXISTING LITERATURE

Clinician experience was not factored into these studies. A report by Raytek,
McCrady, Epstein, and Hirsch (1999) argued that more experienced clinicians
develop stronger therapeutic alliances and are more competent when work-
ing with couples in the context of addiction. Although their study examined
the delivery of ABCT, one could argue that the experience of the clinician
could impact outcome within all of these studies.
The studies reviewed also did not address comorbidity or multiple
addictions. They separated alcohol- and drug-dependent individuals without
addressing reasons for why that would be desirable, nor did they identify
how many alcoholics also use drugs and vice versa. Individuals with sub-
stance dependence might have an addiction to more than one substance
(Teesson, Farrugia, Mills, Hall, & Baillie, 2012). The implications of this for
existing research on BCT could be that other variables (including other addic-
tions or mental health comorbidities) affected the outcomes. Researchers’
implemented BCT strategies of working with couples might be missing
necessary screening for comorbid mental health issues or addictions.
In terms of sample limitations, this review included studies with pri-
marily White, married, English heterosexual samples. Some studies included
cohabiting partners (e.g., Walitzer & Dermen, 2004), but many had marriage
as an inclusion criterion (Fals-Stewart et al., 2000; Halford et al., 2001). Only
five studies considered substance dependence, whereas the other studies
were focused on alcohol use. Separating alcohol and drug use in partici-
pants was consistent across studies. All of the studies selected compared
couple therapy treatment to an active control condition. With the exception
of Vedel et al.’s, (2008) study, BCT was used as an adjunct treatment with
individual therapy, as opposed to a stand-alone condition.
 346 K. Fletcher

Studies focused on men with substance use disorders and their het-
erosexual female partners outnumbered other studies. The studies reviewed
did not state clear rationales for why they chose to focus on only men
or women. Only one study grouped men and women with substance use
disorders together (Vedel et al., 2008), and only four studies focused on
women with substance use disorders (Fals-Stewart, Birchler, & Kelley, 2006;
McCollum et al., 2003; McCrady et al., 2009; Winters et al., 2002). Based on
estimates in the United States, approximately one third of individuals with an
alcohol addiction, and slightly less than half of individuals with drug addic-
tions, are women (Greenfield, Manwani, & Nargiso, 2003). These estimates
might be low, as women are less likely to enter addiction treatment due to
economic and family responsibilities (e.g., no child care; Brady & Ashley,
2005). The high number of women with substance addictions needs to be
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better reflected in treatment research.

The reviewed studies had both gender normative and hetero-normative
inclusion criteria. Only one study addressed same-sex couples (Fals-Stewart,
O’Farrell, & Lam, 2009). Given that the reported incidence of addiction for
lesbian, gay, bisexual, and transgender individuals is higher than for hetero-
sexuals (Cochran & Cauce, 2006; Marshal et al., 2008; McCabe, West, Hughes,
& Boyd, 2013), the lack of research is unacceptable. Furthermore, no studies
included or mentioned transgendered clients. This absence is also glaring,
and future research that is inclusive of these individuals and their partners is
needed.
Another limitation of the articles reviewed was a lack of focus on the
implications of couple therapy for the nonaddicted partner. Halford et al.
(2001) was the only reviewed study that examined the partner’s distress
specifically. Similarly the language of “significant other” or “third party” not
only places the partner at the periphery of the treatment intervention, but
also narrows the lens of who the addiction is impacting. Similarly, the capac-
ities of couples included in the BCT studies had to be very high, as partners
were expected to support and coach their spouse with the addiction. Not
all partners have that emotional capacity, and some might require their own
coaching and support. Perhaps future studies could examine the individual
functioning (mood, stress level, attachment, etc.) of both partners to better
understand whether the partner of the addicted individual experiences any
change in functioning from pretreatment to posttreatment.

LIMITATIONS OF REVIEW

Although a rigorous search strategy was used, it is possible that the review
did not locate all relevant studies. Primarily, the time frame chosen for
reviewed studies excluded early research on couple therapy and addic-
tion. As a result, the review did not capture the complete evolution of
 Couple Therapy Treatments for Substance Use Disorders 347

the approaches examined. The selection criteria using randomized control

couple therapy studies excluded almost all models of couple therapy with
the exception of BCT. Two research groups carried out the majority of the
included research studies, and this could lead to a homogeneous research
agenda. There was little research found countering or questioning the use of
BCT in this context other than authors’ accounts of their own limitations.
Perhaps the greatest limitation within this review was studies addressed
a diverse set of variables, making it difficult to draw firm conclusions about
couple therapy in the context of addiction. The heterogeneity of studies pro-
vides insight into the widespread utility of models like BCT; however, much
more needs to be known about each context and theoretical application.
In describing what is currently known, this review highlights how much
more remains to be learned.
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There were gaps in the literature that are important to highlight.

Primarily, there have been some theoretical pieces written that argue for
novel approaches to treating addiction using couple therapy. For exam-
ple, McCollum et al. (2011) proposed a brief substance-abuse motivational
intervention treatment program for couples struggling with intimate partner
violence. Reflective systemic therapy and emotionally focused couple ther-
apy have also proposed clinical practice models to work with couples in the
context of addiction (Flynn, 2010; Landau-North, Johnson, & Dalgeish, 2011).
This review did not capture these theoretical models because they have yet
to be studied using a randomized clinical trial; however, it is important to
acknowledge their potential for the advancement of knowledge in couple
therapy and addiction.
Some articles that use BCT in interesting ways were also excluded
because they did not meet criteria for review. For example, one study
examined the impact of BCT on intimate partner violence in relationships
with addiction (Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009), and
another examined the impact of BCT on substance abuse and combat-related
posttraumatic stress disorder (Rotunda et al., 2008).

CONCLUSION

Fals-Stewart, Birchler, and O’Farrell (1999) observed in an early study that

32% of 892 applicants for two substance-dependence treatment programs
met the inclusion criteria for couple therapy. A large proportion of clients
entering addiction treatment are suitable for couple treatment; however,
surveys report that well-studied approaches like BCT are not widely used
(Fals-Stewart & Birchler, 2001). A lack of knowledge about models such as
BCT, and missing links in knowledge translation between research findings
and practice could explain the underuse of couple therapy in addiction treat-
ment centers. This review highlights that there are still numerous variables
 348 K. Fletcher

and theoretical modalities that merit investigation in the context of couple

therapy and addiction. Couples therapy clearly has an important role to play
in addiction treatment, and continuing research provides important direction
in terms of new avenues of treatment.

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